Learning from the English National Health Service

 

One of my fantasies about how I might send my post retirement days, once I can no longer work in the clinic seeing patients, is a job working for someone, maybe the Department of Health and Human Services (if it were run by someone other than RFKJR) or some foundation, doing a survey of how other countries do healthcare, because, Heaven Knows, the United States healthcare system could use some help.

Canadian discoverers of insulin

Whenever I get off the boat in some European (especially Scandinavian) country, I head right to the nearest clinic to look around at what they are doing. My wife is off looking at some cathedral, and I'm spooking around a clinic, until the security guys throw me out. I do look suspicious.

One of the first things you notice entering any clinic in Europe is there is no secretary sitting behind a computer ready to grab your insurance card, or throw you out. There is usually just a nurse, ready to take you back to an examining room.

I spent 2 months in England when I was a fourth year medical student on an elective in cardiology at The Royal Brompton Hospital for chest diseases, seeing how they did cardiology in England. The hospital itself looked pretty modest, red brick, six bed wards, but fifty years ago they were doing cardiac catheterization through the brachial artery in the arm, and it wasn't until just 10 years ago we started using that technique in any widespread matter here in the USA where we have the world's best medical care, or so we are told. Using a smaller artery is safer, as you don't put the entire lower extremity (foot, leg) at risk and there is an arcade anatomy in the hand which allows for greater safety.

On weekends, one of the local doctors who made rounds at the Brompton invited me and a couple of other American students out to a smaller hospital in Uxbridge, where we were dumbfounded about how medicine was practiced.

The most dreaded admission for an American intern in those days was the "GI bleeder." This was before the advent of proton pump inhibitors reduced the incidence of gastric and peptic ulcers to near nothing, but in those days the GI bleeder was very common. If you were the intern, you spent all night running up and down to the blood bank getting units of packed red blood cells and after you had transfused the patient with 15 units, if the patient was still bleeding, you called the surgeons to haul him off and cut out part of his stomach or duodenum. 

In England, they transfused 2 units and put the patient to bed and then they came around on rounds the next morning to see if he was still alive. 

We Americans were pretty horrified.

But, the thing is, the patients usually were still alive. They bled down to a certain level, and their blood pressures dropped and they stopped bleeding. 

At least that's the way I remember it.

The other thing I remember is talking with patients who were admitted to hospital and asking when they expected to see their own private physicians make rounds on them. The patients were stupefied. "Why would Dr. Jones see me in hospital?" they asked. In America, you expected your own doctor to see you in hospital, to get you past the worst experience of your life, in person. Not in England. In England, the patient was taken care of in hospital by the hospital doctors and once they were home, the general practitioner got a full report.

Forty years later, that is what we do in America--hospitalists now care for patients in the hospital, just the way they did forty years ago in England. The hospitalists are there 24/7 and take way better care of patients than a GP trying to see patients in his office and then, after office hours, driving some distance to try to figure out what was going on with the patient who got admitted to the hospital, issuing orders over the phone for a patient he had not seen since the day before, if at all.

Sometimes, I think what we are doing in American medicine now is catching up to where England was 40 years ago.

England is where the CAT scan and MRI originated, after all. That much disparaged "socialized medical system" has been responsible for as much or more innovation than our much ballyhooed free enterprise, for profit American system.

Canadians discovered insulin. The English did all the big innovations in diagnostic imaging.

But America, we have always heard, is the pinnacle of medicine. At least, we are the pinnacle of bragging about our medicine.

So, my fantasy is to be sent over to England, Scandinavia, Germany, France and to be allowed to spook around those clinics and hospitals, to make rounds with the doctors, to hear the complaints from the nurses and the patients and the doctors--and surely those systems are well known to be underfunded and beset with problems, but we can also learn from them, I suspect because they have learned to innovate owing to cost constraints and they made decisions not based on considerations of profit, but because they have been looking for greater efficiencies in a cold eyed way.

Even if I were part of a team sent by who knows who, what are the chances anything we discovered about better practices would ever stand a fighting chance of changing things back her in the US of A, where we think nobody has anything to teach us?

But dreaming costs me nothing. 

We can always dream